[10 years of hand traumatology - an epidemiological, structural and economic analysis at a maximum care provider]

Hand surgery in Germany has been subject to structural changes that strongly affect the balance between medicine and economics. On the one hand there is a shift of elective hand surgery from the inpatient to the outpatient sector. On the other hand - so our observations - emergency hand trauma cases are more concentrated in bigger hospitals. Given this background there is a lack of statistical data on the management of hand trauma care and treatment of patients with hand injuries. This article discusses a 10-year-analysis of hand traumatological cases treated at a maximum care hospital regarding epidemiological, structural and economic aspects.

Using a database query using ICD codes, inpatient hand trauma cases were identified between 2009-2018 and analyzed with regard to epidemiological and economic indicators (age, gender, comorbidities, case-mix-index (CMI), revenue, length of stay, length of surgery) using PIVOT tables. Patients under the age of 16 years, forearm fractures and intensive care patients were excluded.

In the study period the typical hand surgical trauma patient was male with an average age of 44 years. The Patient-Clinical-Complexity-Level (PCCL) was 0 in 80 % of all cases. The proportion of work-related injuries averaged around 25 %. The three top diagnose related groups (DRG) were the I32F (18.5 %), X01B (11.3 %) and the I32A (7.2 %). A striking point was the massive increase in the overall number of trauma cases over the years from approx. 300 cases in 2009 to over 1000 cases per year in 2018 with a shift of the main workload to on-call and night-shift hours away from core working times. In the study period 4 of 5 others hospitals located in a distance of 100 km reduced and stopped treatment of emergency hand cases. The average length of a hospital stay was approx. 4-5 days, the average cut/suture time less than 60 minutes and the average CMI 1.23. Those cases generate an average proceed of € 4370 in 2018, whereby the cases generated by the work-related injuries averaged € 387 less.

On the assumption that the number of emergency hand trauma cases did not really increase in the study period we think that there was a concentration of such cases in a few centres still providing extensive treatment for hand injuries while in smaller hospitals care for emergency hand trauma cases is progressively reduced. However, hand injuries may be worth a second thought for economic reasons because they can create reasonable revenues with rather little effort.If a critical number of patients is exceeded, costs of service provisions can be significantly amortized by the proceed generated by treatment. In those hospitals still taking care for acute hand injuries the workload especially in standby duty increased. What may have a negative input on the numbers of treated elective hand surgery cases.